Digital Rectal Examination: Perspectives on Current Attitudes, Enablers, and Barriers to Its Performance by Doctors-in-Training

Background Digital rectal examination (DRE) is a valuable diagnostic tool for diagnosing multiple conditions, but its use has declined in practice. This study sought to provide perspectives on current attitudes, enablers, and barriers to performing DRE for doctors-in-training (DiTs) and explore strategies to improve and facilitate consistent, efficient, and effective execution of DRE. Methodology Self-reported DRE practice among DiTs (n = 1,652) across three metropolitan health service regions in Western Australia was surveyed using a de-identified multiple-response ranking, dichotomous quantitative and qualitative survey. Data were analyzed using SPSS version 27 (IBM Corp., Armonk, NY, USA). Results A total of 452 (27%) DiTs responded to the survey, with an even distribution of key demographics between regions and specialties. The median post-graduate year was 2. Half of DiTs reported being comfortable with performing DRE. Most had training in medical school (71%), while 9.7% had no training in DRE. Chaperone availability, perceived invasiveness, and lack of confidence were key barriers; key enablers were formal training and senior colleague/departmental support. The multivariate logistic regression showed that DiTs who reported being comfortable in performing DRE were significantly and independently associated with being a high-volume practitioner (p < 0.001), confident in diagnosing benign (p < 0.001) or malignant pathology (p < 0.001), perceived adequate DRE training (p < 0.001), prior formal DRE training (p = 0.007), and surgical subspeciality interest (p = 0.030). Conclusions Low levels of confidence and comfort in the performance of DRE among DiTs have resulted in the underutilization of a critical diagnostic tool. Future curriculum and departmental clinical practice interventions should address barriers while promoting enablers.


Introduction
Digital rectal examination (DRE) is a valuable diagnostic tool forming part of a complete physical examination of the gastrointestinal and urogenital systems, providing vital information on various pathologies [1][2][3][4]. These can include general surgical (rectal cancer, hemorrhoids, fistulas), gastroenterological (detection of bleeding such as melaena or hematochezia, assessment of fecal incontinence or constipation), urological (prostate cancer assessment), and gynecological (pelvic floor prolapse or pelvic inflammatory disease) in nature. Furthermore, DRE is a valuable tool in assessing the anal tone in some spinal orthopedic or neurological disorders and is a key part of a multi-trauma secondary survey [1][2][3][4].
Failure to perform an adequate examination can lead to missed opportunities for early intervention, as evidenced by the case that led to this study's conception [5]. The published case report highlighted a series of assumptions by independent treating clinicians of hemorrhoidal bleeding in the context of known hemorrhoids. This resulted in a diagnostic delay that impacted the timely management of anal squamous cell carcinoma (SCC). Historically, surgical teaching has been that the absolute contraindication to DRE is only when the examiner has no fingers or the patient has no anus [3]. Relative contraindications include the presence of an anal fissure and in children. Nevertheless, an inspection is essential and informative [3].
Modern clinical medicine has seen a decline in the use of DRE despite its established role as an aid to the diagnostician [3]. Studies have identified that the lack of training and time or the perception that DRE is of little clinical yield has rendered this physical examination obsolete [6][7][8]. These studies report that most of these examinations are often performed by junior doctors with minimal training and experience with DRE, an issue shared in the medical school curriculum. Medical students often have this vital examination poorly taught in a curriculum with minimal supervision and a lack of exposure during training [8].
In everyday practice, it is not unreasonable to expect that by internship, doctors-in-training (DiTs) should be able to recognize common benign conditions such as thrombosed hemorrhoids, fistula-in-ano, fissure, perianal abscess, melena, benign prostatomegaly, as well as malignant conditions such as low rectal cancer and prostate cancer. In comparison, less common conditions such as perianal SCC, melanoma, extramammary Paget's disease of the anal canal, and prolapse might be challenging for a junior DiT to diagnose clinically. Given that education and experience with DRE are variable, this paper aimed to provide perspectives on the current attitudes, enablers, and barriers to performing DRE for DiTs.
This article was previously presented as a meeting abstract at the 2021 Royal Australasian College of Surgeons Annual Scientific Congress (ASC) on May 11th, 2021, in Melbourne and May 6th, 2019, in Bangkok.

Study population
In Australia, the natural progression of the medical career begins as an intern, then a resident, registrar, fellow of a specialty college, and, finally, a consultant. An intern is a post-graduate year one (PGY1) doctor with provisional registration. A resident is at least PGY2 and possesses general registration. Both interns and residents are supervised by registrars (usually PGY3 and above) who could either be accredited by a specialty college undergoing training or unaccredited.
All 1,652 DiT Interns (n = 322), Residents (n = 761), Registrars (n = 484), and Fellows (n = 85) from three metropolitan regions were invited via multimedia formats (email, hyperlinks, and QR codes on societies' social media sites and at grand rounds and teaching sessions) to participate in an online, de-identified online survey. The self-reported DRE practice Survey Monkey™ was conducted between September 2018 and March 2019 and contained a mix of dichotomous (yes/no), multiple-response, and free-text completion items (Appendices). Multi-platform reminders were sent to improve the response rate. Essential components such as participants' comfort and confidence levels with performing DRE were assessed using a five-point Likert scale. In addition, an internal validity question (likelihood of performing a DRE on a patient presenting with chest pain) was added to the survey questions.
The low-volume practice was defined as performing less than 20 DREs per year, while the high-volume practice was 21 or more. Functional conditions were defined per Talley and O'Connor's clinical examination of the pelvic floor using special tests for pelvic floor dysfunction in a four-step assessment (simple to complex) that helps to inform whether anorectal manometry testing would be beneficial in evaluating incontinence [3].

Statistical analysis
Baseline characteristics and self-reported practice were described using mean (±standard deviation), median (interquartile range), and frequencies/proportions as appropriate. Outcomes for continuous unpaired variables were analyzed with the nonparametric Mann-Whitney U test. Dichotomous outcomes were compared between groups using chi-square or Fisher's exact tests with no adjustment for multiple comparisons. For the primary outcome, the relative comfort of performing a DRE was captured with the Likert scale and expressed as a proportion and 95% confidence interval. A secondary analysis of the primary outcome was performed using multivariate logistic regression to assess the contribution of confounding factors. The correlation between two quantitative variables was evaluated using Spearman's rank correlation test. All analyses were performed using SPSS version 27 (IBM Corp., Armonk, NY, USA), and a two-tailed p-value <0.05 was considered statistically significant.

Permissions
This project was approved as a quality improvement project of negligible risk with authority to publish by the lead Human Research Ethics Sub-Committees on Safety, Quality Improvement and Governance (reference numbers: 28024, 28096). All participants provided informed consent for the publication of their de-identified data.
The response rate was 27% (N = 452), with equal distribution of key demographics across all three health regions. Most respondents were postgraduate years one to four, with most being residents. Most respondents performed low volume amounts of DREs, with minimal amounts of DRE also completed during their education in medical school. High internal validity was demonstrated at 97.3% (Table 1)  Values are the number of participants (%) unless otherwise indicated.

Training
Most respondents had prior DRE training, with most (71%) undergoing training during medical school. More than half of respondents felt that their DRE training needed to be improved, and most (64.4%) did not have a senior colleague independently verify their DRE findings during clinical practice (  Values are the number of participants (%) unless otherwise indicated.

DRE practice
While most respondents would not perform a DRE as part of a routine medical examination, most would perform it as part of the assessment for functional issues such as anal incontinence or constipation. About 5% of respondents said they would never perform a DRE on patients ( Table 3).  Values are the number of participants (%) unless otherwise indicated.

DRE components
While most of the respondents assessed the passive steps of inspection (98.2%), resting anal tone (76.8%), or assessment of the prostate (81.4%), a significant proportion rarely performed the functional DRE components that require active patient participation such as perineum straining. Almost all would inspect for stool/blood on the glove (98.6%) (  Values are the number of participants (%) unless otherwise indicated.

DRE = digital rectal examination; DiT = doctor-in-training
Only around half of the respondents were completely comfortable in performing a DRE (52.5%), and most respondents were confident in the diagnosis of mainly benign pathologies such as hemorrhoids (66.2%) or anal fissures (70.7%). There was a significant decline in confidence levels for diagnosing malignant or functional disorders (

Univariate analysis
Univariate analysis demonstrated significant associations between comfort levels for performing DRE and seniority levels (for both position and number of years post-graduation with p = <0.001). Most DiTs in various specialties were comfortable performing the DRE except for those in General Medicine (25.4%). A significant positive association was also demonstrated in respondents who performed more DREs during medical school or the year preceding this study, with higher confidence levels in performing DRE as part of their clinical practice (  Further, the univariate analysis also demonstrated significant positive associations between seniority levels and confidence in diagnosing malignant, benign, and functional conditions. All specialty subgroups were more confident in diagnosing benign conditions than malignant or functional ones. Of interest, the Emergency, General Practice, and General Medicine specialty interest groups had significantly less confidence in diagnosing conditions on DRE ( Table 7).

Barriers and enablers
Respondents' top three reasons for not performing DREs included being regarded as being too invasive (60%), lack of chaperone (59.3%), and lack of confidence in performing or interpreting findings (47.8%).
Other less frequent reasons included a lesion that precludes a DRE, a patient's age, anticipated patient refusal, the impression of little value/outdated practice, or the perception that DRE is just too much trouble. The key enablers of DRE performance were formal training and senior colleague/departmental support ( Table 8).   (Figure 1).

FIGURE 1: Multivariate logistic regression analysis with being
comfortable in performing DRE as the dependent variable.

Discussion
The DRE remains a useful physical examination component, providing valuable information for diagnosing multiple conditions across various specialties [1][2][3][4]. The lack of training and time, exacerbated by the lack of senior supervision and verification, could have a role in perpetuating the declining confidence in diagnosing anorectal conditions, further reducing its use in clinical medicine. The perception that DRE has low clinical yield may have reduced its usage in clinical practice. In addition, the ubiquity and overwhelming presence of sophisticated technological tools may be a causative factor worth considering. However, modern technology, such as radiological imaging and endoscopies, should not be the answer to clinical medicine.
The perceived invasiveness of DRE was reported as the most common reason for not performing DRE. While not extensively studied, previous studies have suggested that patients are not bothered by the procedure if the procedure and indications have been adequately described [9]. Patients' perspectives on DRE could also be a focus for future studies in facilitating its ongoing use and uptake.
Subspecialty interest groups such as General Practice and Emergency Medicine should be encouraged to undergo training in this clinical tool as they are at the forefront of medicine. As the first point of contact for many patients, they are vital in ensuring that malignant pathologies are not missed or delayed. A missed opportunity could lead to devastating consequences for patients [5].
While respondents primarily performed the inspection and palpation aspects of DRE, other steps of the DRE that mainly involved evaluation of functional status were performed less. These included vital steps in assessing continence issues, such as evaluating pelvic descent during straining or anal sphincter and puborectalis lift. As suggested by previous studies, these steps may not have been adequately taught in medical school, translating to incomplete practice in the clinical field [8].
With the barriers identified, it is hoped that steps can be undertaken to improve the utility of the DRE in medical practice. The education of DRE should occur in medical school and be further cemented early in a junior doctor's career to support their clinical skills. Implementing mannequins in medical school for various clinical skills is exceedingly common. High-fidelity mannequins with interchangeable pelvic and rectal pathologies could be used as introductory models for tactile skills in a workshop or simulation setting, with senior clinicians providing guidance and feedback. Training could be complemented with history and examination, integrating images with common anorectal pathologies to improve identification skills. As technology advances in medical education, virtual reality modules could also be helpful as this allows for real-time feedback from the module paired with clinician supervision.
Translating these skills into real-life practice is challenging due to the nature of the examination. A potential area that could be explored is the implementation of a skills session in an endoscopy or operating theater setting, thereby reducing the anxiety and perceived invasiveness from both the patients and DiTs.
Although it needs to be highlighted with great caution that patients are fully informed and consent documented for this to occur.
There are several limitations of this study. First, the overall response rate was low at 27%. This is common for survey-based research involving health professionals [10][11][12]. This may result in a response bias in our study, where only individuals who felt strongly about the utility of the DRE or the level of DRE training they received would have responded to the questionnaire. In addition, the study only investigated the respondents' self-reported clinical practice, with a lack of correlation between actual clinical skill and the reported confidence and comfort levels, which future studies might want to address.
Several strategies could be explored to mitigate the above limitations for future research. To improve response rates, reminders at various periods could be sent out to prompt responses or provide small incentives for completing the surveys. Another option is to liaise with the institutions' education officers to promote completing such surveys at the start of continuous professional development sessions. Future research should also conduct a subgroup analysis of the different specialties in their attitudes and practices toward DRE. It will be informative to capture the responses from high-volume DRE practitioners from specialty fields compared to relatively low-volume ones. Outcomes learned from such targeted studies could serve as a foundation for developing specialty-specific training tools and practice guidelines to improve the utility of DRE.

Conclusions
The position of DRE as a fundamental clinical tool has been debated in recent years with emerging technological advancements and reservations in its diagnostic yield from the self-sustaining cycle of lack of training and skills, leading to reduced confidence in its performance. DRE has limitations; however, when used in carefully selective presentations based on combined history and examination, it provides robust critical diagnostic information that can significantly impact patient management. The contact details provided will be extracted separately from the study data to maintain anonymity Please note that this research group takes your confidentiality very seriously At no time will the raw data collected in this survey be released to any third party Thank you for taking your time to complete this survey, it is greatly appreciated! End of the survey https://www.surveymonkey.com/r/DREWA . This project was approved as a quality improvement project of negligible risk with the authority to publish by the Safety, Quality Improvement and Governance office (reference numbers: 28024, 28096). As only adult subjects were included, informed consent was obtained from all subjects. All methods were carried out in accordance with relevant guidelines and regulations. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.